WO2009123667A2 - Procédés et compositions incluant des nécessaires de diagnostic permettant de détecter staphylococcus aureus résistant à la méthicilline dans des échantillons - Google Patents

Procédés et compositions incluant des nécessaires de diagnostic permettant de détecter staphylococcus aureus résistant à la méthicilline dans des échantillons Download PDF

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Publication number
WO2009123667A2
WO2009123667A2 PCT/US2008/088356 US2008088356W WO2009123667A2 WO 2009123667 A2 WO2009123667 A2 WO 2009123667A2 US 2008088356 W US2008088356 W US 2008088356W WO 2009123667 A2 WO2009123667 A2 WO 2009123667A2
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WIPO (PCT)
Prior art keywords
staphylococcus aureus
mrsa
gene
cells
methicillin
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PCT/US2008/088356
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English (en)
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WO2009123667A3 (fr
Inventor
Shawn Mark O'hara
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Zeus Scientific, Inc.
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Priority to EP08873707A priority Critical patent/EP2235216A4/fr
Priority to US12/809,090 priority patent/US20120077684A1/en
Publication of WO2009123667A2 publication Critical patent/WO2009123667A2/fr
Publication of WO2009123667A3 publication Critical patent/WO2009123667A3/fr

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    • C—CHEMISTRY; METALLURGY
    • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
    • C12Q—MEASURING OR TESTING PROCESSES INVOLVING ENZYMES, NUCLEIC ACIDS OR MICROORGANISMS; COMPOSITIONS OR TEST PAPERS THEREFOR; PROCESSES OF PREPARING SUCH COMPOSITIONS; CONDITION-RESPONSIVE CONTROL IN MICROBIOLOGICAL OR ENZYMOLOGICAL PROCESSES
    • C12Q1/00—Measuring or testing processes involving enzymes, nucleic acids or microorganisms; Compositions therefor; Processes of preparing such compositions
    • C12Q1/68—Measuring or testing processes involving enzymes, nucleic acids or microorganisms; Compositions therefor; Processes of preparing such compositions involving nucleic acids
    • C12Q1/6876—Nucleic acid products used in the analysis of nucleic acids, e.g. primers or probes
    • C12Q1/6888—Nucleic acid products used in the analysis of nucleic acids, e.g. primers or probes for detection or identification of organisms
    • C12Q1/689—Nucleic acid products used in the analysis of nucleic acids, e.g. primers or probes for detection or identification of organisms for bacteria

Definitions

  • the present invention relates to novel methods, compositions and antibiotic resistant forms and variants thereof, such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Staphylococcus aureus (VRSA), mupirocin- resistant Staphylococcus aureus (mupSA), and the like, in a sample population.
  • MRSA methicillin-resistant Staphylococcus aureus
  • VRSA vancomycin-resistant Staphylococcus aureus
  • mupSA mupirocin- resistant Staphylococcus aureus
  • Staphylococcus Aureus is a major cause of skin, soft tissue, and bloodstream infections that may become rapidly fatal to infected individuals if not treated effectively.
  • SA and methicillin-resistant Staphylococcus aureus are now endemic in many hospitals in the United States and other countries. The incidence of disease across the United States from antibiotic-resistant forms of SA is expected to continue to increase.
  • CDC Centers for Disease Control and Prevention
  • PCR assays to detect nasal colonization of SA have the potential to obtain information in less than 1 hour.
  • a rapid PCR assay as a first step in a population sampling strategy to screen patients for SA would enable significant cost savings, especially when screening for the antibiotic resistant forms of SA such as MRSA, VRSA and the like.
  • Methicillin resistance in SA is caused by the acquisition of an exogenous gene, mecA, that encodes an additional B-lactam-resistant penicillin-binding protein (PBP), termed PBP 2a (or PBP2').
  • the mecA gene is carried by a mobile genetic element, designated staphylococcal cassette chromosome mec (SCC/nec), inserted near the chromosomal origin of replication.
  • SCC/nec staphylococcal cassette chromosome mec
  • the SCCmec DNAs are Integrated at a specific site ⁇ attBscc) adjacent to orfX gene in the methicillin-susceptible S. aureus (MSSA) chromosome.
  • Resistant Staphylococcus aureus Directly from Sterile or Nonsterile Clinical Samples by a New Molecular Assay Patrice Francois, Didier Pittet, Manuela Bento, Be ' atrice Pepey, Pierre Vaudaux, Daniel Lew and Jacques Schrenzel, J. CLIN MICRO, Vol. 41, No. 1; pgs. 254-260, Jan. 2003). More recently, PCR techniques for identifying the SA SCCmec insertion site have enabled the detection of MRSA directly from mixed Staphylococcal nasal samples without the need for SA enrichment or colony isolation. However, it is also important to note that the SCCmec approach has approximately an inherent 5% false positive rate.
  • the present invention provides methods, compositions and diagnostic kits for the detection of Staphylococcus Aureus (SA) and antibiotic resistant forms and variants thereof, such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin- resistant Staphylococcus aureus (VRSA), mupirocin- resistant Staphylococcus aureus (mupSA), and the like, in a sample population.
  • the invention preferably involves the improvements of bacterial sampling by means of SA enrichment, followed by SA cell disruption and amplification procedures incorporating the use of multiplex assays for SA specific genes, such as mecA and coagulase negative Staphylococci (CONS) specific genes such as tufA, for SA identification and identification of its known species. This provides means for controlling for the thirty or more known CONS species in assessing SA samples, especially those CONS species that may carry antibiotic resistance genes, such as SCCmec.
  • the present invention provides novel methods, compositions and diagnostic kits which can enable cost effective management and control for the detection and diagnosis of SA and any of its antibiotic-resistant forms and variants thereof.
  • the present invention also provides improved methods and kits for detection of Methiciltin-Resistant Staphylococcus aureus (MRSA).
  • MRSA Methiciltin-Resistant Staphylococcus aureus
  • the present invention utilizes the mecA gene and the femA gene from SA 1 and in a further preferred embodiment contemplates the use of nuc137 therefrom.
  • the present invention contemplates incorporation of the tufA target gene in place of the femA from S. epidermidis (SE), which enables the further identification of the presence of any and/or all of the presently known species of coagulase negative Staphylococci (CONS), rather than the identification of the single CON species of SE.
  • SE S. epidermidis
  • an objective of the improved methods, compositions and diagnostic kits of the present invention is to address the surprisingly high false positive rates reported as described in the above referenced art.
  • a further objective of the present invention is to provide improved methods, compositions and diagnostic kits for controlling and identifying the presence of all species of coagulase negative methicillin-resistant Staphylococci (MRCONS), which is provided by utilization of the tufA consensus gene sequence.
  • a still further objective of the present invention is to provide for the use of different SA antibody-antigen complexes forming combinations, to selectively enrich for SA and to selectively eliminate all of the known species, and as yet any unknown,
  • Figure 1 is a flow chart depicting a preferred, general nasal swab MRSA carriage assay procedure in accordance with the present invention, using enrichment options with a MRCONS consensus assay for tufA, in combination with mecA and femA-SA (or nuc), and MRSA PCR detection using a DNA derived from a mucosal sample without isolation of the sample DNA from disrupted SA cells.
  • Figure 2 shows a GenBank orfX gene map, showing the relevant gene linkage in MRSA strain USA300. This map illustrates the binding pair (bp) distance of about 7412bp between the extremes of the genes orfX 33721 bp and mecA 41133bp, equal to 7412bp maximum separation distance.
  • the presence of SA and or SE can be identified by species specific orfX PCR.
  • the presence of MRSA and MRSE can be identified in routine gDNA fragment pools averaging 20-23kb by a combination of hybrid probe capture and enrichment followed by multiplex quantitative PCR determining the relative ratios of three markers: SA-orfX, SE-orfX and SCCmecA.
  • SA Staphylococcus aureus
  • MRSA methicillin-resistant Staphylococcus aureus
  • the present invention utilizes a sampling algorithm and Direct PCR from SA disrupted nasal swabs as samples in a commercially available, FDA approved PCR kit such as the above described.
  • Direct nasal SA DNA sample preparation without DNA isolation for PCR provides a faster and less expensive screening method for SA in health care settings.
  • the present invention also focuses on population prevalence of SA relative to MRSA 1 VRSA, ORSA, or CONS/CoNS. For example, SA has been determined to be well established and prevalent in the general population at around 30%, compared to MRSA which is present at approximately 0.8%. In hospitals, SA prevalence remains at approximately 30% while the proportion of MRSA can increase dramatically within its SA population, potentially rising to 60% of the SA population.
  • the present invention thus provides an improved strategy for MRSA screening, utilizing direct PCR for the much simpler and cheaper SA analysis, resulting in a 3 to 4 times less expensive test then presently available MRSA PCR kits.
  • the less expensive SA PCR test is used to rule-out 70% of the samples, which are SA negative, resulting in an approximate overall 50% MRSA screening savings.
  • Determination of SA negative samples in accordance with the present invention is assessed by direct PCR.
  • Direct PCR in the general sample set is accomplished by an initial bacterial cell wall disruption.
  • SA cell disruption and thus amplifiable DNA often exists naturally in nasal mucus samples and can be readily captured via nasal swabs.
  • the cells which are disrupted naturally by the nasal mucosal defense mechanisms and/or by freeze thaw and heating cycles provide amplifiable SA DNA at diagnostically relevant levels compared to the gold standard of culture detection.
  • SA cell disruption can be further accomplished by such techniques well known by those skilled in the art, such as through enzymatic cell wall lysis, achromopeptidase (ACP) proteinase K, Lysozyme, autolysin, sonication wave energy (sonication), electrolysis, pulsed electric field (PEF), electroporation, bead mill homogenizers, centrifugation, ionic or non-ionic detergents, combinations of each, or any means of successful SA cell disruption known in the art.
  • ACP achromopeptidase
  • Lysozyme achromopeptidase K
  • Lysozyme autolysin
  • sonication wave energy (sonication) electrolysis
  • electroporation bea
  • NIMBUS and nisin antibiotic are all contemplated, as well as combinations thereof.
  • PCR inhibitors can be accomplished by utilization of agents such as IgG(s), mucin(s), glycoproteins, nasal RX, blood, heat denaturation, activated charcoal, activated carbon, rapid hybridization, or by any other means known to those skilled in the art.
  • the present invention also contemplates performing on a a nasal sample certain procedures prior to cell wall disruption, followed by direct PCR, such as including, but not limited to, procedures well known in the art such as immunomagnetic enrichment with protein A antibodies, IgG bead binding to SA protein A, thermostable nuclease nuc antibodies, coagulase antibodies, fibronectin FN binding, fibronectin surface binding protein(s), or combinations thereof.
  • DNA extraction and isolation in the practice of the invention can be accomplished by means well known in the art, with the selection algorithm in Figure 1 being particularly advantageous, instead of a direct PCR, in an especially preferred embodiment of the present invention.
  • Genes targeted in any of the amplification steps of the present invention include all of those known in the art for SA or MRSA identification.
  • femA, nuc, sa442, or tufA can be used as SA specific genes, and in SA immunomagnetic procedures, detection of mupirocin resistance uses ileS-2.
  • Coagulase negative Staphylococcus (CONS) are endogenous to human nasal mucosa and are herein considered in connection with the invention as an inherent target for an overall process control in these methods, compositions and kits according to the invention, especially applying the tufA specific gene targets.
  • Amplification assays useful in the present invention include but are not limited to DNA amplification assays, PCR assays incorporating thermostable polymerases, and isothermal amplifications methods.
  • SA direct PCR as comtemplated in the present invention, can be part of a more cost effective and rapid screening test compared to previously described tests of the conventional art, such as the aforedescribed FDA- approved MRSA PCR tests. Initially, it has been found that SA direct PCR will identify SA carriers to rule-out approximately 70% of the general sample population pool (MRSA/VRSA suspect population), resulting in approximately a 50% reduction in screening costs. This improved screening algorithm, as illustrated in Figure 1 , can result in significant cost savings and as such enables the adoption of broader screening and concomitantly fewer SA/MSSA/MRSA/VRSA associated deaths.
  • the present invention contemplates providing cost saving improvements over current, conventional PCR antibiotic resistant SA screening tests of the art, especially for MRSA and VRSA.
  • improvements involve, in part, the incorporation of "direct" nasal SA sample preparation methods applied in combination with a selection process for MRSA and/or VRSA.
  • This selection process utilizes bacterial population demographics such as, but not limited to, the data suggesting that only about 30% of the human population at any one time has nasal colonization with SA.
  • Direct nasal SA sample preparation involves the disruption and liberation of bacterial genomic DNA, specifically SA genomic DNA, but without DNA extraction. Instead of purifying DNA, a disrupted sample is directly transferred to a SA specific PCR reaction mix for testing.
  • the direct sample prep results in a significant savings in total testing time before a result is obtained, reduction in operator hands-on time and a reduction in the reagents and equipment normally used to extract and isolate genomic DNA.
  • the significant reduction in operator hands-on time not only achieves significant cost savings and time to results, but also significantly reduces overall assay complexity and thus contamination potential due to less open tube manipulations. All of the foregoing will be seen to those skilled in the art as advantageous results of the practice of the present invention, by comparison with conventional techniques of the art.
  • the present invention still further provides for the use of different SA antibody- antigen complexes forming combinations, to selectively enrich for SA and to selectively eliminate all of the known species, and as yet any unknown, MRCONS species.
  • These alternatives can include, but are not limited to, IgG bead binding of protein A on all SA cells, thermostable nuclease nuc antibodies, coagulase antibodies, and fibronectin binding solid support systems in combination with fibronectin surface binding proteins found on SA.
  • the present invention contemplates the same principles with the use of nucleic acid based enrichment of SA DNA from all MRCONS DNA, after nasal cell disruption and liberation of the genomic DNA, using disrupted cells and SA DNA specific hybridization methods.
  • genomic DNA genomic DNA isolations and physical manipulations of lysed cells cause random shearing of prokaryotic and eukaryotic gDNA from millions of base pairs (bp) in length, down to narrow size range of 20,000 to 25,000bp (20-25kb).
  • This fragment size (20-25kb) can be considered an important physical linkage limitation unit, by which flanking sequences can be postulated to be "co-isolated”.
  • MRSA is defined as SA strains that acquire the mobile genetic element SCCmecA which always inserts at a specific sequence adjacent to the orfX gene called attBscc.
  • SCCmecA can vary in size and sequence composition designating at least six types, ranging in size from 28kb-66kb. In all of these types the mecA gene is within 10kb of the orfX gene except for Type 111 where this distance is ⁇ 40kb. Fortunately Type III is a rare clinical isolate; however type Ill's mecA gene is located within 20kb of the opposite side of orfX, and thus would be accessible via SA-specific probes from this opposite side. In addition the average fragment length could be increased above ⁇ 23lb by applying more gentle isolation techniques such as offered by ACP cell wall lysis, which is well known for preparing SA whole chromosomes for pulse field gel electrophoresis.
  • GenBank MRSA strain called USA300 a type IVa is illustrated here by way of example of the practice of the invention, but not limitation, as shown in Figure 2 as a general model for orfX based capture from routinely manipulated gDNA fragments of -23kb.
  • the sequenced GenBank genome map of USA300 shows the physical linkage distance of the SA-orfX SCCmec insertion site and the mecA gene are only 7,000bp (7kb). Thus, on average the most gDNA fragments from USA300 captured via SA-orfX hybridization will be physically linked to the flanking mecA gene.
  • a 7kb PCR could be developed to demonstrate this linkage of SA- orfX to mecA defining MRSA, but a novel approach for demonstrating the presence of MRSA gDNA in accordance with the present invention is to first enrich for a SA- sequence specific sequence (e.g. using a SA-orfX specific capture probe) from a routine sample prepared containing SA-gDNA (20kb minimum fragment size), where the majority of SA-orfX containing fragments will on average still be physically linked to SCCmecA gene if MRSA gDNA existed in the sample. After successful enrichment of SA-orfX captured fragments away from any similar sequences containing a confounding SCCmecA such as are routinely found in all CONS, and especially S.
  • a SA- sequence specific sequence e.g. using a SA-orfX specific capture probe
  • MRSA presence criteria would, for example, be ratio quantities as follows:
  • a successful hybridization enrichment assay targeting a specific sequence fragment requiring enrichment from a confounding mixture of fragments would contain three critical elements. First, specific hybridization of appropriately fragmented and single strand denatured sample gDNA enabling desired linkage of flanking sequences; second, capture and enrichment of the specific target fragment; and third, a multiplex relative quantitative assay system to show the ratio of enriched target and sufficient elimination of confounding contamination targets, thereby enabling proof of the presence or absence of specific target sequence(s). Hybridization could be accomplished by any traditional means, as will be well known to those skilled in the art.
  • tp current conventions of synthetically synthesized oligonucleotides hybridization probes there are contemplated for use in the present invention new probe types offering superior performance properties such as higher target affinity and less salt and temperature dependence. Examples of two of these are peptide nucleic acid (PNA) and locked nucleic acids (LNA), both of which could be substituted for DNA capture hybridization probes and/or used in combination to create duplex DNA capture structures called PD-Loop complexes.
  • PNA peptide nucleic acid
  • LNA locked nucleic acids
  • Another novel technique contemplated by the present invention is the optimization of hybridization conditions, such that target fragment Tm is approached in such a manner as to enable only a local regional (or partial) melting of the probe area, while never achieving complete double stranded dissociation.
  • the double- stranded fragment thus obtained is then maintained in a steady state equilibrium of partial denaturation, and annealing would now be receptive to oligonucleotides DNA capture probe hybridization, forming duplex D-loop complex for downstream enrichment.
  • PNA and LNA probes could be substituted, likely facilitating a greater extent of target duplex D-loop formation, capture and enrichment.
  • One critical advantage of capturing double stranded duplex gDNA fragments is the avoidance of SA-SE heteroduplex formation capture complex, which would confound the subsequent assay analysis. It is further anticipated that in accordance with the present invention any of these capture probes can be modified with a capture moiety such as biotin and the like, enabling subsequent capture and enrichment via streptavidin coated beads, preferably magnetic beads. Following capture and washing to enrich and concentrate the target, specific assay(s) would be applied to prove enrichment and presence of the target, as previously described.
  • One particularly preferred assay system is multiplex amplification via quantitative PCRm as previously described, however, it is to be appreciated that isothermal and other nucleic acid systems could also achieve the same result.
  • hybridization + assay An additional modification of the three element system described above could be reduced to a two element system (hybridization + assay) by using the sequence-specific hybridization probes to deliver a sequence-specific cross-linking agent(s) only to the target(s) of interest.
  • PNA and LNA will likely offer the most potential due to their improved performance properties relative to conventional DNA / RNA based probes.
  • the first element of this system entails cross-linking the double stranded fragment of specific sequences, using compounds such as cisplatin, transplatin and psoralen linked to and delivered by hybridization probes. Cross-linking is conducted according to the well known and established DNA cross-linking chemistry conditions, such as UV light etc. After sequence specific cross-linking is complete, the complex mix of gDNA fragments is heated to T/US2008/088356
  • the present invention further considers the use of immunomagnetic enrichment in nasal samples for the removal of known nasal derived PCR inhibitors such as mucus, IgG, blood, nasal treatments and drugs, all contributing to False Negative PCR results.
  • Nasal samples were obtained from nasal swabs after elution with 200 micro liters of TE. Samples were then incubated with or without achromopeptidase (ACP) incubation at 1 Unit/ul 37C for 15 minutes followed by 99C for 5 minutes.
  • ACP achromopeptidase
  • ACP Direct PCR from nasal swab samples can be improved by removal of PCR inhibitors using methods such as cell or DNA enrichment, activated charcoal etc. as described previously.
  • the two previous SA negative samples were again negative for all four treatments via nuc137.
  • the two previous SA positive samples were found to be both positive by Direct-PCR for ALL four treatments, including the untreated "inherent" samples, thereby demonstrating that PCR amplifiable DNA are inherent to nasal mucosal SA and likely all flora.
  • Example 5 lmmunomagnetic and DNA, PNA 1 LNA probe based SA Enrichment lmmunomagnetic enrichment in accordance with the present invention is contemplated prior to sample disruption, and Direct PCR can be expected to improve
  • Direct PCR by eliminating potential PCR inhibitors.
  • any protocol that enriches for the SA bacteria, live or dead, or the nucleic acids thereof, will in theory improve the analytical sensitivity and accuracy of the Direct PCR approach.
  • Consequences of identifying persistently positive / negative groups It is to be appreciated that the majority of SA carriage positive and negative individuals are persistently so, at a constant rate of approximately 30% prevalence. It is believed that this persistent prevalence rate is due to some as yet uncharacterized human factors). Thus, once these persistent positive and negative groups are identified, the need to actively test the general population may be reduced to about the 30% persistent level plus a minor group of transitory individuals.

Abstract

La présente invention concerne des procédés, des compositions et des nécessaires de diagnostic permettant de détecter dans une population échantillon Staphylococcus Aureus (SA) et ses formes et variantes résistant aux antibiotiques tels que Staphylococcus Aureus résistant à la méthicilline (SARM), Staphylococcus Aureus résistant à la vancomycine (SARV), Staphylococcus Aureus résistant à la mupirocine, et analogues. L'invention implique de préférence les améliorations de l'échantillonnage bactérien par enrichissement de SA, puis des procédures de rupture et d'amplification de cellules intégrant l'utilisation d'essais multiplex de gènes spécifiques de SA tels que mecA et de gènes spécifiques de staphylocoques négatifs à la coagulase (CONS) tels que tufA, de façon à identifier SA et à identifier ses espèces connues. L'invention permet ainsi de lutter contre au moins trente espèces connues de CONS par évaluation d'échantillons de SA, en particulier celles des espèces CONS qui sont susceptibles de porter des gènes de résistance aux antibiotiques tels que SCCmec.
PCT/US2008/088356 2007-12-26 2008-12-26 Procédés et compositions incluant des nécessaires de diagnostic permettant de détecter staphylococcus aureus résistant à la méthicilline dans des échantillons WO2009123667A2 (fr)

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EP08873707A EP2235216A4 (fr) 2007-12-26 2008-12-26 Procédés et compositions incluant des nécessaires de diagnostic permettant de détecter staphylococcus aureus résistant à la méthicilline dans des échantillons
US12/809,090 US20120077684A1 (en) 2007-12-26 2008-12-26 Methods and Compositions Including Diagnostic Kits For The Detection In Samples Of Methicillin-Resistant Staphylococcus Aureus

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US61/009,125 2007-12-26

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US20150240294A1 (en) * 2008-12-30 2015-08-27 Qiagen Hamburg Gmbh Method for detecting methicillin-resistant staphylococcus aureus (mrsa) strains
WO2017072078A1 (fr) * 2015-10-29 2017-05-04 Thomas Bruderer Procédé d'immuno-essai soustractif et bandelette de dosage d'immunochromatographie à écoulement latéral pour réaliser le procédé
US9777335B2 (en) 2001-06-04 2017-10-03 Geneohm Sciences Canada Inc. Method for the detection and identification of methicillin-resistant Staphylococcus aureus
US11834720B2 (en) 2005-10-11 2023-12-05 Geneohm Sciences, Inc. Sequences for detection and identification of methicillin-resistant Staphylococcus aureus (MRSA) of MREJ types xi to xx

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US9777335B2 (en) 2001-06-04 2017-10-03 Geneohm Sciences Canada Inc. Method for the detection and identification of methicillin-resistant Staphylococcus aureus
US10577664B2 (en) 2001-06-04 2020-03-03 Geneohm Sciences Canada, Inc. Method for the detection and identification of methicillin-resistant Staphylococcus aureus
US10801074B2 (en) 2001-06-04 2020-10-13 Geneohm Sciences Canada, Inc. Method for the detection and identification of methicillin-resistant Staphylococcus aureus
US11834720B2 (en) 2005-10-11 2023-12-05 Geneohm Sciences, Inc. Sequences for detection and identification of methicillin-resistant Staphylococcus aureus (MRSA) of MREJ types xi to xx
US20150240294A1 (en) * 2008-12-30 2015-08-27 Qiagen Hamburg Gmbh Method for detecting methicillin-resistant staphylococcus aureus (mrsa) strains
WO2017072078A1 (fr) * 2015-10-29 2017-05-04 Thomas Bruderer Procédé d'immuno-essai soustractif et bandelette de dosage d'immunochromatographie à écoulement latéral pour réaliser le procédé
US10914738B2 (en) 2015-10-29 2021-02-09 Thomas Bruderer Subtractive immunoassay method and lateral flow immunochromatography assay strip for performing the method

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EP2235216A2 (fr) 2010-10-06
US20120077684A1 (en) 2012-03-29
EP2235216A4 (fr) 2011-04-06

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